What information should I provide to a healthy, non‑pregnant woman of reproductive age who is considering the depo‑provera (medroxyprogesterone acetate) injection as a long‑acting, provider‑administered contraceptive?

Depo-Provera (Medroxyprogesterone Acetate) Patient Information

Depo-Provera is a highly effective contraceptive injection given every 13 weeks that prevents pregnancy with a failure rate of approximately 3% with typical use, but you must understand that menstrual changes are expected, return to fertility is delayed after stopping, and it does not protect against sexually transmitted infections. 1

How Effective Is It?

• Depo-Provera is one of the most effective reversible contraceptives available, with a 12-month failure rate of 0-0.7% in clinical studies and approximately 3% in real-world use. 2, 3
• This effectiveness is comparable to IUDs and better than birth control pills (5-8% failure rate), condoms (18% failure rate), or fertility awareness methods (24% failure rate). 2
• You must use condoms every time for STI protection, as Depo-Provera provides no protection against HIV, chlamydia, gonorrhea, or other sexually transmitted infections. 1, 3

How and When You Get the Injection

• The injection is given every 13 weeks (91 days) as either 150 mg intramuscularly (in the muscle) or 104 mg subcutaneously (under the skin). 1
• Your first injection should ideally be given within the first 5 days of your menstrual period to ensure you are not pregnant. 1
• If started within the first 7 days of your period, you are protected immediately with no backup contraception needed. 2, 1
• If started more than 7 days after your period begins, you must use backup contraception (condoms or abstinence) for 7 consecutive days after the injection. 1

What to Expect Before Your First Injection

• No pelvic exam, Pap smear, breast exam, or blood tests are required before starting Depo-Provera, which means you can start the same day as your visit. 1, 4
• Your provider will measure your weight and BMI for future monitoring. 4
• Your provider will confirm you are not pregnant using established criteria. 1

Expected Menstrual Changes (Most Important Side Effect)

• Nearly all users experience menstrual changes, and this is normal, not harmful. 5, 3
• During the first few months, expect irregular bleeding, spotting, or unpredictable bleeding patterns. 5, 3
• With continued use, bleeding typically decreases and many women stop having periods entirely (amenorrhea), which is safe and not harmful. 2, 3
• If you experience heavy or prolonged bleeding that bothers you, NSAIDs (like ibuprofen) for 5-7 days can help. 5
• If bleeding remains unacceptable despite treatment, discuss alternative contraceptive methods with your provider. 5

Return to Fertility After Stopping

• Fertility does not return immediately after stopping Depo-Provera. 1, 4
• Time to ovulation ranges from 15 to 49 weeks (approximately 4-12 months) after your last injection. 1, 6
• Some women may take up to 18 months to conceive after discontinuation. 4, 7
• This delayed return to fertility is temporary and does not cause permanent infertility. 7

Repeat Injection Schedule

• Schedule your repeat injection every 13 weeks (91 days). 1
• You can receive your injection up to 2 weeks late (14 weeks from last injection) without needing backup contraception. 2, 1
• If more than 2 weeks late (more than 14 weeks), you can still get the injection if you are not pregnant, but you must use backup contraception for 7 days. 1
• Consider emergency contraception if you had unprotected sex while late for your injection. 2

Other Common Side Effects

• Weight gain is common, particularly in the first 6 months of use. 5, 8
• If you gain more than 5% of your body weight in the first 6 months, you are likely to gain more weight with continued use. 4
• Mood changes can occur; if you have a history of depression, you should be monitored closely. 3
• Headaches, breast tenderness, and abdominal bloating may occur. 8

Bone Density Concerns and Long-Term Use

• There is no time limit on how long you can use Depo-Provera, despite older warnings about bone density. 4
• Depo-Provera causes temporary bone density loss that substantially recovers after stopping the medication. 4
• You do not need bone density scans, even if you use Depo-Provera for more than 2 years. 4
• To protect bone health during use, ensure daily calcium intake of 1,300 mg and vitamin D intake of 600 IU, engage in regular weight-bearing exercise, and avoid smoking. 4

Who Should NOT Use Depo-Provera

Do not use Depo-Provera if you have: 1

• Known or suspected breast cancer or history of breast cancer
• Active blood clots or history of blood clots in legs or lungs
• Stroke or heart attack history
• Significant liver disease
• Unexplained vaginal bleeding
• Allergy to medroxyprogesterone acetate

Use caution or consider alternatives if you have: 2

• Positive antiphospholipid antibodies (blood clotting disorder)
• High risk for osteoporosis or existing osteoporosis
• Very active lupus (SLE)

Monitoring During Use

• No routine blood work is needed while using Depo-Provera. 4
• Your provider will monitor your weight at follow-up visits. 4
• Report any concerning symptoms like severe headaches, chest pain, leg pain, or heavy bleeding to your provider immediately. 3

Key Points to Remember

• Depo-Provera is highly effective but requires you to return every 13 weeks for repeat injections. 1
• Menstrual changes are expected and normal—irregular bleeding initially, then often no periods at all. 5
• Always use condoms for STI protection. 1
• Fertility returns slowly after stopping, taking 4-18 months on average. 1, 4
• You can use Depo-Provera for as long as it works for you—there is no 2-year limit. 4
• No routine exams or blood tests are needed before starting or during use. 1, 4